Here is a scenario you may have seen in your office: a teenager or young adult, usually male, who is suddenly failing at life. He may be having anger problems, personality changes, and sleep or appetite changes. He may have gotten good grades in school and is now failing all of his classes. He is not “running with a bad crowd”; in fact, he is not running with any crowd. He is usually home, playing on his computer. He says he is fine and denies feeling depressed. Drug tests come back negative. You may have prescribed antidepressants or stimulants empirically for depression or attention-deficit/hyperactivity disorder, but there has been no response. This patient does not act like anything you have seen before.
This young man may very well be obsessively playing a massively multiplayer online role-playing game (MMORPG), in which players create virtual identities for them-selves and become immersed in an online fantasy world. MMORPGs are played on personal computers, as opposed to console games (e.g., X-Box, Playstation), which do not offer the social interaction of MMORPGs and are designed to have a defined ending. There have been reports of addiction to console games, but computer-based MMORPGs carry a much higher risk. Currently, there are an estimated 12.5 million MMORPG subscribers worldwide.1 As the popularity of these games has grown, the problem of compulsive online gaming has escalated.
MMORPGs are designed to require increasing playing time to achieve higher levels and obtain more gold, weapons, skills, and power in a virtual world. At the highest levels, players must band together into guilds to go on quests or raids that can require 10 or more hours of continuous play, with some players reporting playing over 70 hours per week.2 Most players can play casually and never have a problem, but an estimated six to 20 percent of players play to the exclusion of such essential activities as work, school, family responsibilities, and even eating and sleeping.3 Reports of failed marriages, neglected families, lost jobs, derailed educations, and even suicide have appeared in the medical literature and the lay press.4 Attempts to stop playing can result in a withdrawal syndrome consisting of restlessness, depression, vivid dreams about the game, anger, and excessive sleep.5 The problem is especially acute in China and South Korea, where governments have set mandatory limits on playing time and government-sponsored rehabilitation clinics have opened. The Chinese government estimates that 13 percent of the country's Internet users younger than 18 years are addicted to the Internet.6
Persons with this disorder exhibit behaviors usually associated with drug and alcohol dependence, including a need for increasing amounts of exposure to the substance (i.e., the game), denial of the adverse effects it has on their lives, repeated unsuccessful attempts to stop playing, and continued playing in the face of serious consequences such as divorce, job loss, and school failure.6 This disorder is not yet catalogued in the Diagnostic and Statistical Manual of Mental Disorders, which was last published more than 10 years ago, but it is important for family physicians to recognize this problem and to ask about time spent playing Internet computer games when examining a patient who exhibits unexplained or resistant symptoms of depression, anxiety, or sleep disorders, or employment, marital, or school problems. Patients should be referred to a mental health provider who specializes in addictions. Inpatient and outpatient rehabilitation therapy is available, as is On-Line Gamers Anonymous, an online support and recovery program based on a 12-step model (http://www.olganonboard.org).